February is a fitting month to celebrate American Heart Month, and there’s much to celebrate: smoking rates are down; understanding of the importance of exercise and diet is up; and new, diverse medications help to prevent and treat cardiovascular disease.
There’s also a world of new life-saving technologies and procedures such as wearable defibrillators and percutaneous coronary interventions, along with valve replacements and bypass surgeries, which seem almost old-hat, by now.
Yet heart disease is still the leading cause of death for men and women in the US, with 1 in 4 deaths due to heart disease.
Prevalence of cardiovascular disease increases with age, and in older adults, even routine cardiovascular treatments must be used with caution.
“With heart health especially, you have to look at patients’ goals of care: are you looking to alleviate symptoms or improve function, or are you trying to live longer?” says Beth Rosenberg, MD, EdD, FACC, a primary care provider for Piedmont Health Services’ Burlington PACE center as well as the “house cardiologist” for the Burlington and Pittsboro PACE centers.
At PACE, the federally funded Program of All-Inclusive Care for the Elderly, these conversations around goals of care happen every day, says Rosenberg, but are not practiced so widely in the larger community.
With 20 years in cardiology practice in the Triangle, Dr. Rosenberg knows about hearts. As a cardiologist, she found caring for her older patients very rewarding. Her work with older patients at PACE combines her cardiology background and general medicine skills with a passion for caring for older adults.
Interprofessional Geriatric Fellowship Program
Dr. Rosenberg is also a current Fellow in the Division of Geriatric Medicine’s Interprofessional Geriatric Fellowship Program, where she continues to learn about geriatric medicine from multiple perspectives of pharmacy, nursing, and dentistry, while sharing her cardiology expertise. The IP Geriatric Fellowship brings providers from different disciplines together for a one-year program of shared expertise and geriatric focus.
Decisions regarding prevention and treatment of cardiovascular disease are more challenging with older patients, who have multiple chronic conditions and take more medications. Care can be further complicated by the lack of research and guidelines specifically for patients over 75.
“The problem with cardiology guidelines is that none of them apply to my patients,” says Dr. Rosenberg. “Blood pressure can be a whole conundrum, in and of itself.”
Statins in older patients are also a topic of considerable debate.
For older adults with hypertension and diabetes, it might make sense to be on statins. But if taking statins brings muscle pain and means a patient has a hard time getting up in the morning, “that’s not worth it,” says Dr. Rosenberg. In adults 75 and over, it may be reasonable to discontinue statins where there is functional decline or reduced life expectancy, she says.
When considering heart surgery for older patients, Dr. Rosenberg says that “much of the time it goes well, but when it doesn’t, it goes very poorly.” Patients over 80 require a different discussion, with full consideration of complicating factors. For patients in their 80s, particularly those who are frail and living with COPD, diabetes, or kidney disease, surgery brings real potential for harm.
Older people metabolize anesthesia differently. In cases of borderline dementia, “if you send them for surgery, they may not come out better.” Dr. Rosenberg says that some older patients can be good candidates for surgery, but the key to successful outcomes is selecting good candidates. Dr. Rosenberg’s heart health advice for those between 55 and 75 years of age is to use available care and treatment options to decrease risk of cardiovascular disease, provided they don’t negatively impact quality of life.
“Being older is the time in one’s life when the balance of risks or negative impacts of various drugs or interventions on quality of life may start to outweigh benefits.”
Regular, safe exercise – supported and monitored for vulnerable patients – and a heart-healthy diet may well be the best “medicine” for old and young hearts alike.